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00128
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
0MCIAL USE ONLY
SITE LOCATIONN Pc�- h&rSt%m e TM# 3 - a Q � — /Q
OWNER'S NAME Pat C. a c p a'41 PHONE
MAILING ADDRESS S a w�- .
PERSON INTERVIEWED PCHD Complaint #
I / Name & Relationship (i.e., owner, tenant, etc.
DATE
PROPOSE]
ADDRESS
TYPE FAC1L1TY4j-bS1,oa.,
CLu
PHONE Jgy�'- 655 -,5-) q `/ 'r3J, -3i
REGISTRATION#
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
I, as owner, o r po ed a nt of owner agree to the conditions stated on this form.
SIGNATURE TITLE 6 DATE
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title DAE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) .
PC -RP 99NIL